Bjørn Lofterød

Preoperative gait analysis has a substantial effect on orthopedic decision making in children with cerebral palsy: comparison between clinical evaluation and gait analysis in 60 patients.

Background There is still some debate regarding the role of 3-dimensional gait analysis in routine preoperative evaluation of children with cerebral palsy. The aim of this prospective study was to evaluate to what extent introduction of 3-D gait analysis changes preoperative surgical planning. Method Before gait analysis, 60 ambulatory children aged 10 (4–18) years with spastic cerebral palsy had a specific surgical plan outlined, based on clinical examination by orthopedic surgeons. After gait analysis, the proposed surgical procedures were reviewed to determine the frequency with which the treatment plans changed. A multidisciplinary team assessed the gait analysis. Results Treatment plans for 42 of the 60 patients were altered after gait analysis. Surgical treatment was recommended for 49 patients whereas 11 were recommended non-surgical treatment. Of the 253 specific surgical procedures proposed, 97 procedures were not recommended after gait analysis and 65 additional procedures were recommended after the analysis. Thus, the number of procedures proposed was reduced by 13%. A total of 318 specific surgical procedures were proposed either clinically, by gait analysis, or both. There was overall agreement between the referring orthopedic surgeons and gait analysis in 156 of these 318 procedures (49%). Gait analysis proposed more surgery for psoas tenotomy and rectus femoris transfer, whereas less surgery was proposed for other soft tissue and bony procedures. There was good accordance between gait analysis recommendations and the surgery performed subsequently (92%). Interpretation Gait analysis provided important additional information that modified preoperative surgical planning to a high degree. The high accordance between recommendations and surgery performed suggests that surgeons seriously consider the gait data and treatment recommendations.

Results of treatment when orthopaedic surgeons follow gait‐analysis recommendations in children with CP

The aim of the present study was to assess the outcome of orthopaedic surgery in ambulant children with cerebral palsy, when the orthopaedic surgeons followed the recommendations from preoperative three‐dimensional gait analysis. 55 children, mean age 10y 11mo, were clinically evaluated by orthopaedic surgeons who proposed a surgical treatment plan. After gait analysis and subsequent surgery, three groups were defined. In group A, there was agreement between clinical proposals, gait‐analysis recommendations, and subsequent surgery in 128 specific surgical procedures. In group B, 54 procedures were performed based on gait analysis, although these procedures had not been proposed at the clinical examination. In group C, 55 surgical procedures that had been proposed after clinical evaluation were not performed because of the gait‐analysis recommendations. The children underwent follow‐up gait analysis 1 to 2 years after the initial analysis. The kinematic results were satisfactory, with improvement in most of the gait parameters in children who had undergone surgery and no significant deterioration in those who were not operated. In group A, there were significant improvements in maximum hip extension in stance, minimum knee flexion in stance, timing of maximum knee flexion in swing and knee range of motion, maximum ankle dorsiflexion in stance, and mean femur rotation in stance. In group B, there were significant improvements in maximum hip extension in stance, minimum knee flexion in stance, and knee range of motion. We conclude that gait analysis was useful in confirming clinical indications for surgery, in defining indications for surgery that had not been clinically proposed, and for excluding or delaying surgery that was clinically proposed.

Gait improvement surgery in ambulatory children with diplegic cerebral palsy

Background and purpose — Instrumented 3-D gait analyses (GA) in children with cerebral palsy (CP) have shown improved gait function 1 year postoperatively. Using GA, we assessed the outcome after 5 years and evaluated parental satisfaction with the surgery and the need for additional surgery. Patients and methods — 34 ambulatory children with spastic diplegia had preoperative GA. Based on this GA, the children underwent 195 orthopedic procedures on their lower limbs at a mean age of 11.6 (6–19) years. On average, 5.7 (1–11) procedures per child were performed. Outcome measures were evaluation of gait quality using the gait profile score (GPS) and selected kinematic parameters, functional level using the functional mobility scale (FMS), and the degree of parental satisfaction. Results — The mean GPS improved from 20.7° (95% CI: 19–23) preoperatively to 15.4° (95% CI: 14–17) 5 years postoperatively. There was no significant change in GPS between 1 and 5 years. The individual kinematic parameters at the ankle, knee, and hip improved statistically significantly, as did gait function (FMS). The mean parental satisfaction, on a scale from 0 to 10, was 7.7 (2–10) points. There was a need for additional surgical procedures in 14 children; this was more frequent in those who had the index operation at an early age. Interpretation — The main finding was that orthopedic surgery based on preoperative GA gave marked improvements in gait function and quality, which were stable over a 5-year period. Nevertheless, additional orthopedic procedures were necessary in almost half of the children and further follow-up with GA for more than 1 year postoperatively is recommended in children with risk factors for such surgery.

Changes in lower limb rotation after soft tissue surgery in spastic diplegia: 3-dimensional gait analysis in 28 children

Background and purpose Rotational osteotomies are usually necessary to correct pronounced rotational deformities in ambulant children with cerebral palsy. The effects of soft tissue surgery on such deformities are unclear. In this retrospective study, we determined whether multilevel soft tissue surgery, performed to correct deformities in the sagittal plane, would also have an effect on rotational parameters. Patients and methods We examined 28 ambulant children with spastic diplegia with an average age of 12 (7–19) years. They underwent multilevel soft tissue surgery (with 6 surgical procedures per child on average). 3-dimensional gait analysis was performed preoperatively and at an average follow-up of 1–2 years. The indications for surgery were abnormalities in the sagittal plane. Gait analysis data from healthy children were used in defining normal ranges of kinematic variables. For assessment of changes in the transverse plane, the angles of foot progression, hip rotation, and pelvic rotation were studied. Results The transverse plane kinematic results showed no statistically significant postoperative changes when the preoperative parameters were within the normal range (within 2 SD of the mean of the normal material). In limbs where the preoperative values were abnormal (more than 2 SD above the normal mean), there was a mean reduction in internal foot progression of 12° (p = 0.01) and a mean reduction in external pelvic rotation of 6° (p = 0.02). The effect was more pronounced in children under 12 years of age. Internal hip rotation was not significantly reduced. Interpretation When the preoperative rotational parameters were abnormal, multilevel soft tissue surgery resulted in improved transverse plane kinematics. This could be of importance in preoperative decision making, especially when there is doubt as to whether to include rotational osteotomies in multilevel operations in younger children.

Can Persistent Drop Foot After Calf Muscle Lengthening Be Predicted Preoperatively

UNLABELLED Calf muscle lengthening usually corrects equinus gait satisfactorily in stance. While in swing, the foot remains in drop foot in approximately half the limbs. The aim of this study was to evaluate if any preoperative clinical findings or kinematic and kinetic data could predict the outcome regarding drop foot. The study included 34 children with cerebral palsy. The average age was 9.3 years. Only children with preoperative maximum ankle dorsiflexion in stance and maximum ankle dorsiflexion in swing more than 2 standard deviations below the normal mean were included. The children underwent preoperative and postoperative clinical examination and gait analysis. Forty calf muscle lengthenings were performed (26 tendo-achilles lengthenings, 14 gastrocnemius recessions). Nineteen of 40 limbs remained in drop foot despite satisfactory correction in stance. There was a significant association between postoperative drop foot and increased preoperative maximum plantar flexion in initial swing (P = .004; odds ratio, 0.906). A limited number of tests of preoperative selective motor control of dorsiflexion of the ankle indicated that normal function is strongly indicative of postoperative normal swing phase. There were no significant associations between postoperative drop foot and preoperative clinical findings, gait function, type of gait pattern, type of cerebral palsy, and type of operation. Preoperative maximum plantar flexion in an initial swing of less than -42 degrees and a preoperative normal selective motor control of dorsiflexion of the ankle are strongly indicative of postoperative normal swing phase. A lower selective motor control score rather than normal function is not predictive of either normal swing or drop foot. LEVEL OF EVIDENCE 2.

Pain and rehabilitation problems after single-event multilevel surgery including bony foot surgery in cerebral palsy. A series of 7 children.

Background and purpose — Surgical correction of foot deformities as part of single-event multilevel surgery (SEMLS) to optimize postoperative training is sometimes indicated in ambulatory children with cerebral palsy. We have, however, experienced excessive postoperative pain and rehabilitation problems in a number of these patients. We therefore investigated children who underwent such procedures regarding postoperative rehabilitation and pain, gait parameters 1 year after surgery, and mobility 5 years after surgery. Patients and methods — 9 children with diplegic cerebral palsy who had also undergone bony foot surgery were identified from a cohort of 70 children treated with SEMLS according to a standardized protocol. 2 children were excluded due to mental retardation and atypical surgery, and 7 patients (4 of them boys) were included. The children and their parents underwent a semi-structured interview on average 5 (3–7) years after the surgery. Gait parameters preoperatively and 1 year postoperatively were compared. Results — 5 children had experienced regional pain syndrome and considerable sociopsychological problems during the first postoperative year. 5 years after surgery, 4 of the 5 children still had hypersensitive and painful feet, 2 had lost their ability to walk, 1 child was no longer self-reliant in daily care, and 3 were wheelchair bound. There were, however, no clinically significant differences in functional mobility scale (FMS) or gait parameters preoperatively and 1 year postoperatively. Interpretation — We found troublesome postoperative rehabilitation and poor outcomes in this series of children who had undergone simultaneous multilevel surgeries and bony foot corrections. Caution is warranted when treating marginally ambulatory children with bilateral spastic cerebral palsy and foot deformities.